Impact of Stakeholders As with any intervention, stakeholders must be considered. For population health programs and interventions, the stakeholder group is large. If you are providing care to an individual patient, you may only consider the needs of the patient, family, and healthcare team.  In population health, stakeholders may include the city, state, and national governments, along with the population and community impacted. In population health programs and interventions the goal is achieve the "greatest good for the greatest number" (Bentham, 1996). The focus of population health is broad and the needs of all stakeholders must be considered.Primary Prevention Primary prevention targets disease or disability prevention. These interventions focus on health promotion and address a universal population. Primary prevention interventions occur across settings, including healthcare organizations, school-based health clinics, complementary and alternative medicine (CAM) clinics, social media, as well as private homes (American Academy of Pediatrics, 2018). One example of a  primary prevention intervention is a program to promote breastfeeding to reduce the occurrence of childhood obesity and comorbidities. Another example is vaccination programs to reduce the occurrence of infectious diseases.Secondary Prevention Secondary prevention focuses on identifying already occurring health problems or conditions prior to the onset of serious or long-term problems. These interventions address selected or targeted symptomatic populations. The objective of secondary prevention is early diagnosis and initial treatment or stabilization of disease in the early stages before it causes significant morbidity and mortality. These interventions can occur in all the some venues as primary interventions, as well as in emergency departments and retail-based clinics, such as Walgreen's (Moreland & Curran, 2018).Tertiary Prevention Tertiary prevention aims to slow or stop the progression of disease. These interventions target individuals who are already diagnosed with a disease condition and work to restore function and reduce disease-related complications (Moreland & Curran, 2018). The third level of prevention is tertiary prevention, which is the act of managing a disease after diagnosis. Let's return to Kevin to see how this level of prevention relates to him. During Kevin's colonoscopy, the provider discovered polyps. The polyps were removed. And the pathology report reveals cancer. Tertiary prevention is the process of intervention and treatment. It involves managing the disease post-diagnosis to slow or stop disease progression. Kevin's story illustrates an example of primary, secondary and tertiary prevention, including interventions for each level of prevention. Latest evidence suggests that therapeutic intervention strategies for Alzheimer's disease must be reconsidered as pathogenesis is now known to vary at different stages of the disease (Bu et al., 2016) ...

1. Impact of Stakeholders
As with any intervention, stakeholders must be considered. For
population health programs and interventions, the stakeholder
group is large. If you are providing care to an individual
patient, you may only consider the needs of the patient, family,
and healthcare team. In population health, stakeholders may
include the city, state, and national governments, along with the
population and community impacted. In population health
programs and interventions the goal is achieve the "greatest
good for the greatest number" (Bentham, 1996). The focus of
population health is broad and the needs of all stakeholders
must be considered.Primary Prevention
Primary prevention targets disease or disability prevention.
These interventions focus on health promotion and address a
universal population. Primary prevention interventions occur
across settings, including healthcare organizations, school -
based health clinics, complementary and alternative medicine
(CAM) clinics, social media, as well as private homes
(American Academy of Pediatrics, 2018). One example of a
primary prevention intervention is a program to promote
breastfeeding to reduce the occurrence of childhood obesity and
comorbidities. Another example is vaccination programs to
reduce the occurrence of infectious diseases.Secondary
Prevention
Secondary prevention focuses on identifying already occurring
health problems or conditions prior to the onset of serious or
long-term problems. These interventions address selected or
targeted symptomatic populations. The objective of secondary
prevention is early diagnosis and initial treatment or
stabilization of disease in the early stages before it causes
significant morbidity and mortality. These interventions can
occur in all the some venues as primary interventions, as well as
in emergency departments and retail-based clinics, such as
Walgreen's (Moreland & Curran, 2018).Tertiary Prevention

2. Tertiary prevention aims to slow or stop the progression of
disease. These interventions target individuals who are already
diagnosed with a disease condition and work to restore function
and reduce disease-related complications (Moreland & Curran,
2018).
The third level of prevention is tertiary prevention, which is the
act of managing a disease after diagnosis. Let's return to Kevin
to see how this level of prevention relates to him. During
Kevin's colonoscopy, the provider discovered polyps. The
polyps were removed. And the pathology report reveals
cancer. Tertiary prevention is the process of interventio n and
treatment.
It involves managing the disease post-diagnosis to slow or stop
disease progression. Kevin's story illustrates an example of
primary, secondary and tertiary prevention, including
interventions for each level of prevention.
Latest evidence suggests that therapeutic intervention strategies
for Alzheimer's disease must be reconsidered as pathogenesis is
now known to vary at different stages of the disease (Bu et al.,
2016). What tertiary prevention intervention is helpful for the
effective prevention and treatment of Alzheimer's disease?
Preterm birth is a leading contributor of perinatal morbidity and
mortality (Matei et al., 2019). What tertiary prevention
intervention is needed to help reduce the occurrence of preterm
birth?Population Health Interventions
Population health interventions typically address one of the
three levels of prevention and target the population as a whole.
For example, an intervention may encompass individuals who
are at risk for breast cancer, influenza, or impacted by a
tornado. These interventions are not free. Funding plays a
significant role in the creation and management of population
health interventions, and health policy informs the type of
interventions as well as the resource allocation.

3. After viewing “Lyft, Uber, and Sidecar” and the “EatWith”
videos, predict the problems that will continue to plague
innovators in the flexible workforce. Use at least two sources in
addition to the text to support your position. Respond to at least
two classmates’ posts.
Course text: Weathington, B. L. & Weathington, J. G.
(2020). Compensation and benefits: Aligning rewards with
strategy, updated edition. Zovio.
Eat with [Video segment]. (2014). In Reason TV, The sharing
economy vs. the government . Retrieved
from https://fod.infobase.com/OnDemandEmbed.aspx?token=93
730&wID=100753&loid=373417&plt=FOD&w=640&h=360&f
Width=660&fHeight=410
Lyft, Uber and Sidecar [Video segment]. (2014). In Reason
TV, The sharing economy vs. the government. Retrieved from
https://fod.infobase.com/OnDemandEmbed.aspx?token=93730&
wID=100753&loid=373417&plt=FOD&w=640&h=360&fWidth=
660&fHeight=410
Laws making workplaces, restaurants, and bars
completely smoke-free can reduce heart attack
hospitalizations by 8%–17% within a year.3,5,6
Federal laws that address U.S. air quality have
contributed to a decrease of 54% of six common
air pollutants since 1980.7
INTRODUCTION
The health of the American public has improved on many fronts
over
the last decades—from decreasing incidence of lung cancer in

4. men
to large reductions in the number of childhood lead poisoning
cases.
But as previous modules highlight, many diseases and illnesses
are
increasing in frequency. Though the reasons for these increases
are often
unknown, to the extent that the causes are recognized or
suspected,
preventive measures are desirable. Public health focuses on
prevention
of disease and health promotion rather than the diagnosis and
treatment
of diseases.
WHAT IS PREVENTION?
Prevention activities are typically categorized by the following
three
definitions:
1. Primary Prevention—intervening before health effects occur,
through
measures such as vaccinations, altering risky behaviors (poor
eating
habits, tobacco use), and banning substances known to be
associated
with a disease or health condition.8,9
2. Secondary Prevention—screening to identify diseases in the
earliest
stages, before the onset of signs and symptoms, through
measures such
as mammography and regular blood pressure testing.10
3. Tertiary Prevention—managing disease post diagnosis to
slow or stop

5. disease progression through measures such as chemotherapy,
rehabili-
tation, and screening for complications.11
PREVENTION
QUICK FACTS
Actions such as the
Clean Air Act as well
as anti-smoking
campaigns have had
a significant preventive
impact on public
health.1,2,3
States play a crucial role
in promoting both local
and federal prevention
efforts and also contrib-
ute to prevention through
their own initiatives.2,3
Beyond individual
prevention efforts, local
community actions can
be particularly effective
in bringing about changes
that prevent or reduce
environmentally-related
illness and disease.4
PREVENTION PICTURE OF AMERICA2 3
Most prevention suggestions are primary or secondary
prevention efforts for individuals. Yet, in the context
of environmental health, prevention is much broader,

6. because exposure to many contaminants is beyond
the control of individuals and historically has been
most effectively reduced by government programs
and regulations12 (e.g., Pollution Prevention Act13;
Clean Air Act1). Traditionally, environmental public
health has focused on reducing exposure to environ-
mental hazards known to be related to disease.
Increasing emphasis is placed on upstream inter-
ventions—eliminating the source of the hazard
rather than just preventing or reducing exposure.14
This type of elimination has often required action
by individuals as well as governments at the
federal, state, and local levels.
THE PREVENTION FRAMEWORK
LOCAL PREVENTION
Beyond individual prevention efforts, local commu-
nity actions can be particularly effective in bringing
about changes that prevent or reduce environmen-
tally-related illness and disease. Strategies ranging
from community education to neighborhood aware-
ness around an environmental health issue are some
of the actions that can be taken at the local level.
Zoning laws that provide incentives for the creation
of bike paths or that reduce the number or density
of liquor stores are actions taken by local govern-
ments for the benefit of a community.15 Information
sharing between neighborhood associations, faith
communities, community-based organizations, and
other local groups can highlight gaps in service and
facilitate coordinated efforts to achieve public health
outcomes.
STATE PREVENTION
States play an important role in promoting both
local and federal prevention efforts and also contrib-

7. ute to prevention through their own initiatives.
For example, inspections and regulation enforce-
ment at food service establishments, swimming
pools, hazardous waste disposal sites, and other
locations help prevent illness and disease statewide.
State-sponsored efforts support health screening
programs, anti-smoking campaigns, and health
education. As partners with federal agencies, states
assist in implementation of programs such as the
CDC’s Childhood Lead Poisoning Prevention
Program and the CDC’s National Heart Disease and
Stroke Prevention Program.
Figure 1. The Spectrum of Prevention8
Influencing Policy and
Legislation
Mobilizing neighborhoods
and communities
Fostering coalitions
and networks
Changing internal
practices and policies of
agencies and institutions
Educating healthcare
providers and other
professionals
Promoting
community
education

8. Strengthening
individual knowledge
and skills
PREVENTION 2 3
NATIONAL PREVENTION
National prevention activities include initiatives,
regulatory programs, and policies that establish
nationwide programs to reduce both the presence
of and exposure to harmful agents in the environ-
ment (e.g., the Clean Water Act, National Tobacco
Control Program, National Asthma Control
Program). Many agencies are involved in activities
that either directly or indirectly reduce public
exposure. The Department of Health and Human
Services, which includes the CDC and the U.S.
Food and Drug Administration; the Environmental
Protection Agency (EPA); the Department
of Housing and Urban Development (HUD); and
the Department of Agriculture (USDA) all have
a hand in prevention efforts.
KEY COMPONENTS OF PREVENTION16
Individual, local, state, and federal efforts to prevent
environmentally-caused illness and disease have had
some success, but a more comprehensive effort would
be useful in meeting the overall environmental health
challenges facing the United States. The following
activities and initiatives can lead to understanding
and reducing the nation’s incidence of environmentally-
caused disease.

9. AWARENESS AND EDUCATION
• Inform and educate decision-makers, public health
practitioners, health care providers, and individuals
about science-based health prevention approaches
that will have the greatest benefit and impact
on public health.
• Provide information on effectiveness of interven-
tions to inform policies.
• Educate workers both in and out of the health field
who may have daily contact with people at high
risk for disease and injury. These individuals can
encourage healthy behaviors, screen for certain
health risks, and contribute to education of the
community.17
• Provide the public with health education information.
• Work with the media to highlight public health issues.
PREVENTION PICTURE OF AMERICA4 5
• Establish programs to proactively distribute informa-
tion to targeted groups—those at high risk for disease
or injury.
Research
• Identify and support an environmental public health
research agenda at the national level. This research
would address knowledge gaps in suspected and
emerging links between exposure to harmful environ-
mental agents and health outcomes.

10. Surveillance at all levels
• Monitor environmental risk areas or situations and
determine the prevalence of environmentally-linked
health outcomes. Identify national, state, or commu-
nity environmental health issues; develop measures
to track those issues; and implement widespread
surveillance to help identify relationships between
environmental hazards and health concerns.
Hazard evaluation at the national, state,
and local levels
• Implement hazard assessments as needed. Respond
to high-risk situations, identify and quantify hazard-
ous agents, and facilitate exposure reduction.
Improvement of the public health system at the
national, state, and local levels
• Enhance and revitalize the environmental health system
at all levels. Build and improve long-term strategic
partnerships, commitments by all stakeholders, and
additional resources, as well as collaboration with
environmental regulatory agencies and development
of a competent and effective environmental public
health workforce.16
Proactive behavior by individuals
• Make healthy lifestyle choices, choose environmental -
ly-friendly products and services, and conscientiously
try to minimize the environmental impact of yourself
and your family. Become informed about the issues,
and be proactive in prevention initiatives promoting

11. health and preventing illness and disease.
PREVENTION 4 5
THE NATIONAL ENVIRONMENTAL
PUBLIC HEALTH TRACKING
NETWORK
Many of the above activities are dependent on the
availability of information to link diseases and
environmental exposures. Laboratory studies
contribute to our understanding, but without
coordinated tracking of environmental hazards,
exposures, and diseases, the picture is often
fragmented and inconclusive. The CDC has
responded to this need with the National Environ-
mental Public Health Tracking Network.18 This
Network has established information-system
standards to facilitate integration of local, state,
and national databases of environmental hazards,
environmental exposures, and health effects.
These data allow federal, state, and local agencies,
among others, to monitor and distribute informa-
tion about environmental hazards and disease
trends. As trends and linkage between environmen-
tal hazards and disease are uncovered, preventive
actions can be taken to protect communities.
SUCCESSFUL PREVENTION INITIATIVES
Actions such as the Clean Air Act as well as anti-
smoking campaigns have achieved a significant
preventive impact on public health.1,2,3 The following
success stories demonstrate how these initiatives relate
to the advancement of environmental public health.
CLEAN AIR PREVENTION INITIATIVES

12. One of the most substantial environmental pollution
success stories has been the reduction in levels of air
pollutants throughout the United States (see Outdoor
Air Quality chapter). While national air quality has
improved since the early 1990s, air quality problems
still exist, presenting many challenges in protecting
public health and the environment.
Air pollution is a major problem that can affect every-
one.19 Studies show links between air pollution and
a number of health problems, such as an increased
risk for heart attacks, and it can affect individuals with
asthma and other lung conditions. Children and the
elderly are often the most vulnerable to the effects
of air pollution.20
1955 The Air Pollution Act of 1955 provides federal research
funds for studying air pollution.
1963 The Clear Air Act of 1963 establishes a federal program
authorizing research for ways
to monitor and control pollution.
1967 The Air Quality Act of 1967 expands the federal
government’s activities to begin enforcing
areas subject to interstate pollution transport and conducting
ambient air monitoring studies
and industrial source inspections.
1970 The Clean Air Act of 1970 brings about a major shift in
the government’s role in controlling
air pollution. Comprehensive federal and state regulations are
developed to reduce
emissions from industrial and mobile sources.
1970 The U.S. Environmental Protection Agency (EPA) is

13. established to implement the require-
ments of the 1970 Clean Air Act.
1977
and
1990
Major amendments are added to the 1970 Clean Air Act
ensuring continuation of the Air
Quality Standards, increasing the federal government’s air
quality authority and responsibili-
ties, and establishing new programs for acid rain and toxic air
pollutants.19
Figure 2. Timeline of Key Federal Clean Air Initiatives
PREVENTION PICTURE OF AMERICA6 7
Figure 2 provides a timeline that illustrates key fed-
eral initiatives designed and implemented to reduce
air pollution and related illnesses across the nation.
The EPA has set national outdoor air quality stan-
dards for the following six common air pollutants:
• Particulate matter (PM)
• Ozone (O3)
• Carbon monoxide (CO)
• Nitrogen dioxide (NO2)
• Sulfur dioxide (SO2)
• Lead (Pb)
EPA monitors outdoor air quality concentrations
of these pollutants and produces estimates of emis-
sions based on monitored data plus calculations

14. of pollutants emitted by vehicles, factories, and other
sources. EPA air quality trends show that air quality
has improved nationally since 1980.7 Between 1980–
2007, while increases were seen in the gross domestic
product, the number of vehicle miles traveled, over-
all energy consumption, and the U.S. population,
total emissions of these six common air pollutants
decreased by 52%.7 Other significant improvements
since 1970 include a 70% reduction of air toxics from
large industrial sources, new cars that are more than
90% cleaner, and the end of the production of most
ozone-depleting chemicals.20
The CDC Air Pollution and Respiratory Health
Branch in the National Center for Environmental
Health works to prevent environmentally-related
respiratory illnesses and studies indoor and outdoor
air pollution. This CDC program collects and analyzes
respiratory health data, implements asthma interven-
tions to ensure scientific information is translated
into public health practice, establishes and maintains
partnerships to control asthma, works to prevent car-
bon monoxide poisoning, and studies the effects
of forest fire smoke and other airborne contaminants.21
WHAT YOU CAN DO
In addition to national legislation and programs
regarding clean air, individuals can also take a proac-
tive approach to reduce air pollution as well as their
exposure to harmful air pollutants.20
Practice energy conservation – using less energy
and recycling reduces air pollution generated
by power generating and manufacturing facilities.
• Recycle paper, plastic, glass bottles, cardboard,

15. and aluminum cans.
• Conserve energy by turning off appliances and
lights when not in use.
• Buy ENERGY STAR products, such as energy-
efficient lighting and appliances.
• Connect outdoor lights to a timer or use solar
lighting to reduce your use of electricity.
• Use rechargeable batteries.
• Lower the thermostat on the water heater
to 120°F.
Reduce your consumption of fossil fuels by driving
less or using more efficient vehicles designed
to burn less gasoline and oil.
• Choose efficient, low-polluting vehicles.
• Plan trips; save gasoline and reduce air pollution.
• Keep tires properly inflated and aligned and get
regular engine tune-ups and car maintenance
to increase your fuel efficiency.
• During summer, fill the gas tank during cooler
evening hours to decrease evaporation and
reduce the formation of ozone.
• Avoid waiting in long drive-through lines; park
your car and go in.
• Use public transportation, walk, or ride a bike.
• Join a carpool or vanpool to get to work.

16. Reduce your personal exposure to air pollutants.
• Use low volatile organic compounds (VOC)
or water-based paints, stains, finishes, and paint
strippers.
• Choose not to smoke inside the home; ask
visitors to smoke outside.
• Keep woodstoves and fireplaces well maintained.
• Test the home for radon.
• Avoid spilling gas; do not top off the tank and
replace gas cap tightly.
• Check daily air quality forecasts and associated
health concerns.
PREVENTION 6 7
SECONDHAND SMOKE
PREVENTION INITIATIVES
Secondhand smoke, also called environmental
tobacco smoke (ETS), is the mixture of gases and
particles given off by burning cigarettes, pipes, and
cigars as well as the smoke exhaled by smokers.22
Breathing secondhand smoke, even in small
amounts, is dangerous to human health and can
cause lung cancer and an increased risk of heart
disease, including heart attack, in adult nonsmokers22
(see Secondhand Smoke section in Homes chapter).
Laws and policies for smoke-free environments
have been initiated at the national, state, and

17. local levels. Nationally, several laws and policies
restricting smoking in public places have been
adopted.23 Federal law prohibits smoking on
domestic airline flights and interstate buses.
Smoking is also banned in most federally-owned
buildings, and the Pro-Children Act of 1994
prohibits smoking in buildings where federally-
funded services are provided to children.24
While these federal smoking restrictions are
important, the most comprehensive smoke-free
laws have originated at the local level. Local initia-
tives engage communities in public education,
raise awareness of the health risks of secondhand
smoke, and increase public awareness of policies
that provide protection from exposure risks.25
As increasing numbers of communities successfully
implemented comprehensive laws making work-
places, restaurants, and bars completely smoke-free,
states began enacting similarly comprehensive laws.25
The first state laws restricting smoking in public
places were passed in Arizona, Connecticut, and
Minnesota between 1973–1975.26 Over the years
a number of other states enacted limited smoking
restrictions. In the 1990s, California became the
first state to restrict smoking in most indoor work-
places and places, including restaurants and bars.25
From 2002–2005, Delaware, New York, Massachu-
setts, Rhode Island, and Washington state imple-
mented comprehensive state smoke-free laws.25
By April of 2014, 24 states and the District
of Columbia had comprehensive laws in effect
requiring all private workplaces, restaurants, and
bars to be smoke-free.27 According to the American
Nonsmokers’ Rights Foundation, over 49%

18. of Americans live under comprehensive state
In a 2006 report, the U.S. Surgeon General
reached the following conclusions regarding
control of secondhand smoke exposure:25
• The scientific evidence indicates that there
is no risk-free level of exposure to second-
hand smoke.
• Only eliminating smoking in indoor spaces
fully protects nonsmokers from secondhand
smoke exposure; separating smokers from
nonsmokers, cleaning the air, and ventilat-
ing buildings cannot completely eliminate
exposure.
• Workplace smoking restrictions are effective
in reducing secondhand smoke exposure and
lead to less smoking among covered workers.
• Establishing smoke-free workplaces is the
only way to ensure secondhand smoke
exposure does not occur in the workplace.
• The majority of workers in the United States
are covered by smoke-free policies.
• Evidence from peer-reviewed studies shows
that smoke-free policies do not have an
adverse economic impact on the hospitality
industry.
PREVENTION PICTURE OF AMERICA8 9

19. or local smoke-free laws.27 The prevalence of U.S.
nonsmokers’ exposure to secondhand smoke dropped
by half between 1988–1991, when most Americans
were exposed, and 2007–2008. This decline was likely
driven in large part by the widespread adoption of
state and local laws and voluntary business policies
prohibiting smoking in indoor workplaces and public
places.25
A number of studies conducted in a range of com-
munities, states, regions, and countries have reported
substantial and rapid reductions in heart attack
hospitalizations following the implementation
of smoke-free laws.28 In 2010, the Institute of Medi-
cine, after reviewing these studies and related
evidence, concluded that smoke-free laws reduce
heart attacks.28 In addition, three meta-analyses
of studies on this topic have estimated pooled effect
sizes of 8%,3 10%,5 and 17%.6
WHAT YOU CAN DO
There are steps individuals can take to protect
themselves and their family from exposure
to secondhand smoke25:
• Make the home and car smoke-free.
• Visit smoke-free restaurants and public places.
• Ask people not to smoke around you and
your children.
• Use a smoke-free daycare center.
CONTINUED PREVENTION
SUCCESS
Clean air and secondhand smoke prevention are
just two examples of the many successes that have

20. occurred through the use of proactive preventive
measures. Many more success stories will emerge
as individuals, communities, and other stakeholders
take on a more active role in environmental public
health.
PREVENTION 8 9
1. EPA. The Clean Air Act: Protecting human health and the
environ-
ment since 1970 as the U.S. economy has grown [online]. 2012.
[cited 2013 May 8]. Available from URL:
http://www.epa.gov/air/
sect812/economy.html.
2. CDC. State smoke-free laws for worksites, restaurants, and
bars—
United States, 2000—2010. MMWR 2011;60(15):472–5.
3. Meyers DG, Neuberger JS, He J. Cardiovascular effect of
bans
on smoking in public places. J Am Coll Cardiol 2009;54:1249–
55.
4. Institute of Medicine. The community. In:The Future of the
Public’s
Health in the 21st Century. Washington (D.C.): The National
Academies Press, 2003.
5. Mackay DF, Irfan MO, Haw S, Pell JP. Meta-analysis of the
effect
of comprehensive smoke-free legislation on acute coronary
events.
Heart 2010;96(19):1525–30.

21. 6. Lightwood JM, Glantz SA. Declines in acute myocardial
infarction
after smoke-free laws and individual risk attributable to
secondhand
smoke Circulation 2009;120:1373–9.
7. EPA. Air trends. Basic information [online]. 2008 May 8.
[cited 2010
Apr 13]. Available from URL: http://www.epa.gov/air/airtrends/
sixpoll.html.
8. Wallace RB. Primary prevention. In: Breslow L, Cengage G,
editors. Encyclopedia of Public Health [online]. 2006. [cited
2010
Mar 30]. Available from URL: http://www.enotes.com/public-
health-
encyclopedia/primary-prevention.
9. Canadian Association of Physicians for the Environment.
Primary
prevention. Children’s Environmental Health Project [online].
2000.
[cited 2010 Mar 30]. Available from URL: http://www.cape.ca/
children/prev.html.
10. Wallace RB. Secondary prevention. In: Breslow L, Cengage
G,
editors Encyclopedia of Public Health [online]. 2006. [cited
2010
Mar 30]. Available from URL: http://www.enotes.com/public-
health-
encyclopedia/secondary-prevention.
11. Wallace RB. Tertiary prevention. In: Breslow L Cengage G,
editors.

22. Encyclopedia of Public Health [online]. 2006. [cited 2010 Mar
30].
Available from URL: http://www.enotes.com/public-health-
encyclo-
pedia/tertiary-prevention.
12. EPA. Pollution Prevention Laws and Policy [online].2012
Feb
16.[cited 2013 May 8]. Available from URL:
http://www.epa.gov/p2/
pubs/laws.htm.
13. Pollution Prevention Act of 1990, Pub. L. No. 101–508, 104
Stat.
1388–321 et seq (As Amended Through P.L. 107–377,
December
31, 2002) [online]. 2002. [cited ]. Available from URL:
http://www.
epw.senate.gov/PPA90.pdf.
14. Cohen L, Chehemi S, Chavez V, editors. Prevention is
primary:
Strategies for community well-being. San Francisco (CA):
Jossey-
Bass; 2007.
15. Frieden, T. Government’s role in protecting health and
safety.
N Engl J Med 2013;368:1857–1859.
16. CDC. A national strategy to revitalize environmental public
health
services [online]. 2003. [cited 2010 Mar 31]. Available from
URL:
http://www.cdc.gov/nceh/ehs/Docs/nationalstrategy2003.pdf.

23. 17. Rattray T, Brunner W, Freestone J. The new spectrum of
prevention:
a model for public health practice.Contra Costa Health Services
[online] 2002 Apr [cited 2010 Mar 30]. Available from URL:
http://
www.cchealth.org/topics/prevention/pdf/new_spectrum_of_
prevention.pdf.
18. CDC. National Environmental Public Health Tracking
Program.
Background [online]. 2009 July 13. [cited 2010 Mar 31].
Available
from URL: http://www.cdc.gov/nceh/tracking/background.htm.
19. EPA History of the Clean Air Act [online]. 2008 Jul 7.
[cited 2010
Apr13]. Available from URL: http://www.epa.gov/air/caa/caa_
history.html.
20. EPA. The plain English guide to the Clean Air Act [online].
2007.
[cited 2010 Apr 13]. Available from URL:
http://www.epa.gov/air/
caa/peg/peg.pdf.
21. CDC. Air pollution and respiratory health [online]. 2009
May.
[cited 2010 Apr 14]. Available from URL:
http://www.cdc.gov/nceh/
airpollution/about.htm.
22. EPA. Smoke-free homes and cars program. Health effects of
expo-
sure to secondhand smoke [online]. 2008 Feb 29. [cited 2010
Apr 14]. Available from URL:
http://www.epa.gov/smokefree/health

24. effects.html.
23. CDC Smoking and Tobacco Use, Secondhand Smoke (SHS)
Facts
[online]. 2013 Jun 10. [cited http://www.cdc.gov/tobacco/data_
statistics/fact_sheets/secondhand_smoke/general_facts/index.ht
m.
24. National Cancer Institute. Fact sheet: Secondhand smoke:
questions and answers [online]. 2007 Aug 01.[cited 2010
Apr14].
Available from URL:
http://www.cancer.gov/cancertopics/factsheet/
Tobacco/ETS.
25. CDC. The health consequences of involuntary exposure to
tobacco
smoke: a report of the Surgeon General. Secondhand smoke
what
it means to you [online].2006. [cited 2010 Apr 14]. Available
from
URL: http://www.surgeongeneral.gov/library/secondhandsmoke/
secondhandsmoke.pdf.
26. DHHS. Reducing the Health Consequences of Smoking: 25
Years
of Progress. A Report of the Surgeon General. DHHS
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27. American Nonsmokers’ Rights Foundation. Summary of
100%
smokefree state laws and population protected by 100% U.S.

25. smokefree laws [online]. July 3, 2014 [cited 2014 Jul 8].
Available
from URL: http://www.no-
smoke.org/pdf/SummaryUSPopList.pdf.
28. Institute of Medicine. Secondhand smoke exposure and
cardiovas-
cular effects: making sense of the evidence. Washington (D.C.):
The National Academies Press, 2010.
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PU36CH31-Kolodny ARI 11 February 2015 9:9
The Prescription Opioid and
Heroin Crisis: A Public

27. Health Approach to an
Epidemic of Addiction
Andrew Kolodny,1,2,3 David T. Courtwright,4
Catherine S. Hwang,5,6 Peter Kreiner,1 John L. Eadie,1
Thomas W. Clark,1 and G. Caleb Alexander5,6,7
1 Heller School for Social Policy and Management, Brandeis
University, Waltham,
Massachusetts 02454; email: [email protected],
[email protected],
[email protected], [email protected]
2 Phoenix House Foundation, New York, NY 10023
3 Global Institute of Public Health, New York University, New
York, NY 10003
4 Department of History, University of North Florida,
Jacksonville, Florida 32224;
email: [email protected]
5 Center for Drug Safety and Effectiveness, 6 Department of
Epidemiology, Bloomberg School of
Public Health, Johns Hopkins University, Baltimore, Maryland
21205;
email: [email protected]
7 Division of General Internal Medicine, Department of
Medicine, Johns Hopkins Medicine,
Baltimore, Maryland 21205; email: [email protected]
Annu. Rev. Public Health 2015. 36:559–74
First published online as a Review in Advance on
January 12, 2015
The Annual Review of Public Health is online at
publhealth.annualreviews.org
This article’s doi:
10.1146/annurev-publhealth-031914-122957

28. Copyright c© 2015 by Annual Reviews.
All rights reserved
Keywords
prescription drug abuse, heroin, overdose deaths, chronic pain,
opioid,
addiction
Abstract
Public health authorities have described, with growing alarm, an
unprece-
dented increase in morbidity and mortality associated with use
of opioid pain
relievers (OPRs). Efforts to address the opioid crisis have
focused mainly on
reducing nonmedical OPR use. Too often overlooked, however,
is the need
for preventing and treating opioid addiction, which occurs in
both medical
and nonmedical OPR users. Overprescribing of OPRs has led to
a sharp
increase in the prevalence of opioid addiction, which in turn has
been asso-
ciated with a rise in overdose deaths and heroin use. A
multifaceted public
health approach that utilizes primary, secondary, and tertiary
opioid addic-
tion prevention strategies is required to effectively reduce
opioid-related
morbidity and mortality. We describe the scope of this public
health crisis,
its historical context, contributing factors, and lines of evidence
indicating

29. the role of addiction in exacerbating morbidity and mortality,
and we provide
a framework for interventions to address the epidemic of opioid
addiction.
559
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PU36CH31-Kolodny ARI 11 February 2015 9:9
INTRODUCTION

33. Over the past 15 years, the rate of opioid pain reliever (OPR)
use in the United States has
soared. From 1999 to 2011, consumption of hydrocodone more
than doubled and consumption
of oxycodone increased by nearly 500% (42). During the same
time frame, the OPR-related
overdose death rate nearly quadrupled (15). According to the
United States Centers for Disease
Control and Prevention (CDC), the unprecedented increase in
OPR consumption has led to the
“worst drug overdose epidemic in [US] history” (58). Given the
magnitude of the problem, in 2014
the CDC added opioid overdose prevention to its list of top five
public health challenges (13).
Overdose mortality is not the only adverse public health
outcome associated with increased
OPR use. The rise in opioid consumption has also been
associated with a sharp increase in
emergency room visits for nonmedical OPR use (69) and in
neonatal abstinence syndrome (57).
Moreover, from 1997 to 2011, there was a 900% increase in
individuals seeking treatment for
addiction to OPRs (66, 68). The correlation between opioid
sales, OPR-related overdose deaths,
and treatment seeking for opioid addiction is striking (Figure
1).
Addiction is defined as continued use of a drug despite negative
consequences (1). Opioids are
highly addictive because they induce euphoria (positive
reinforcement) and cessation of chronic
use produces dysphoria (negative reinforcement). Chronic
exposure to opioids results in structural
and functional changes in regions of the brain that mediate

34. affect, impulse, reward, and motivation
(83, 91). The disease of opioid addiction arises from repeated
exposure to opioids and can occur
in individuals using opioids to relieve pain and in nonmedical
users.
Another important feature of the opioid addiction epidemic is
the relationship between OPR
use and heroin use. According to the federal government’s
National Survey on Drug Use and
Health (NSDUH), 4 out of 5 current heroin users report that
their opioid use began with OPRs
(54). Many of these individuals appear to be switching to heroin
after becoming addicted to
OPRs because heroin is less expensive on the black market. For
example, in a recent sample of
0
1
2
3
4
5
6
7
8
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

35. 2010
R
at
e
Year
Opioid sales kg/10,000
Opioid deaths/100,000
Opioid treatment admissions/10,000
Figure 1
Rates of OPR sales, OPR-related unintentional overdose deaths,
and OPR addiction treatment admissions,
1999–2010. Abbreviation: OPR, opioid pain reliever. Source:
10.
560 Kolodny et al.
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PU36CH31-Kolodny ARI 11 February 2015 9:9
Non-Hispanic white Non-Hispanic black
50
40
30
20
10
0
Pe
rc
en
t
o
f a
ll

40. h
er
o
in
a
d
m
is
si
o
n
s
ag
ed
1
2
an
d
o
ve
r
2001 2003 2005 2007 2009 2011 2001 2003 2005 2007 2009
2011
12–19 years

41. 20–34 years
35–44 years
45 years or older
Year
Figure 2
Heroin admissions, by age group and race/ethnicity: 2001–2011.
Source: 68.
opioid-addicted individuals who switched from OPRs to heroin,
94% reported doing so because
OPRs “were far more expensive and harder to obtain” (16, p.
24).
The increased prevalence of opioid addiction has also been
associated with increases in heroin-
related morbidity and mortality. For example, since 2001,
heroin addiction treatment admissions
for whites ages 20–34 have increased sharply (Figure 2). During
this time frame, heroin overdose
deaths among whites ages 18–44 increased by 171% (14).
HISTORY OF OPIOID ADDICTION IN THE UNITED STATES
The current opioid addiction crisis is, in many ways, a replay of
history. America’s first epidemic of
opioid addiction occurred in the second half of the nineteenth
century. In the 1840s, the estimated
national supply of opium and morphine could have supported a
maximum of 0.72 opioid-addicted
individuals per 1,000 persons (18). Over the next 50 years,
opioid consumption soared by 538%.

42. It reached its peak in the mid-1890s, when the supply could
have supported a maximum of ∼4.59
opioid-addicted individuals per 1,000 persons. The ceiling rate
then began to decline, and by 1920
there were no more than 1.97 opioid-addicted individuals per
1,000 persons in the United States.
The epidemic had diverse origins. Mothers dosed themselves
and their children with opium
tinctures and patent medicines. Soldiers used opium and
morphine to treat diarrhea and painful
injuries. Drinkers alleviated hangovers with opioids. Chinese
immigrants smoked opium, a practice
that spread to the white underworld. But the main source of the
epidemic was iatrogenic morphine
addiction, which coincided with the spread of hypodermic
medication during 1870–1895. The
model opioid-addicted individual was a native-born white
woman with a painful disorder, often
of a chronic nature.
Nineteenth-century physicians addicted patients—and, not
infrequently, themselves—because
they had few alternatives to symptomatic treatment. Cures were
scarce and the etiology of painful
conditions was poorly understood. An injection of morphine
almost magically alleviated symptoms,
pleasing doctors and patients. Many patients continued to
acquire and inject morphine, the sale
of which was poorly controlled.
The revolutions in bacteriology and public health, which
reduced diarrheal and other diseases
commonly treated with opium; the development of alternative
analgesics such as aspirin; stricter

43. www.annualreviews.org • The Opioid Addiction Epidemic 561
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PU36CH31-Kolodny ARI 11 February 2015 9:9
prescription laws; and admonitions about morphine in the lay
and professional literature stemmed
the addiction tide. One important lesson of the first narcotic
epidemic is that physicians were
educable. Indeed, by 1919, narcotic overprescribing was the
hallmark of older, less-competent

47. physicians. The younger, better-trained practitioners who
replaced them were more circumspect
about administering and prescribing opioids (5).
For the rest of the twentieth century, opioid addiction epidemics
resulted from transient in-
creases in the incidence of nonmedical heroin use in urban
areas. After World War II, these
epidemics disproportionately affected inner-city minority
populations, such as the large, heavily
publicized increase in ghetto heroin use and addiction at the end
of the 1960s (24, 37).
THE SHARP RISE IN PRESCRIPTION OPIOID
CONSUMPTION
In 1986 a paper describing the treatment of 38 chronic pain
patients concluded that OPRs could
be prescribed safely on a long-term basis (61). Despite its low-
quality evidence, the paper was
widely cited to support expanded use of opioids for chronic
non-cancer pain. Opioid use increased
gradually in the 1980s. In 1996, the rate of opioid use began
accelerating rapidly (38). This
acceleration was fueled in large part by the introduction in 1995
of OxyContin, an extended
release formulation of oxycodone manufactured by Purdue
Pharma.
Between 1996 and 2002, Purdue Pharma funded more than
20,000 pain-related educational
programs through direct sponsorship or financial grants and
launched a multifaceted campaign
to encourage long-term use of OPRs for chronic non-cancer pain
(86). As part of this campaign,
Purdue provided financial support to the American Pain Society,

48. the American Academy of Pain
Medicine, the Federation of State Medical Boards, the Joint
Commission, pain patient groups,
and other organizations (27). In turn, these groups all advocated
for more aggressive identification
and treatment of pain, especially use of OPRs.
For example, in 1995, the president of the American Pain
Society introduced a campaign en-
titled “Pain is the Fifth Vital Sign” at the society’s annual
meeting. This campaign encouraged
health care professionals to assess pain with the “same zeal” as
they do with vital signs and urged
more aggressive use of opioids for chronic non-cancer pain (9).
Shortly thereafter, the Veterans’
Affairs health system, as well as the Joint Commission, which
accredits hospitals and other health
care organizations, embraced the Pain is the Fifth Vital Sign
campaign to increase the identi-
fication and treatment of pain, especially with OPRs. Similarly,
the American Pain Society and
the American Academy of Pain Medicine issued a consensus
statement endorsing opioid use for
chronic non-cancer pain (31). Although the statement cautioned
against imprudent prescribing,
this warning may have been overshadowed by assertions that the
risk of addiction and tolerance
was low, risk of opioid-induced respiratory depression was
short-lived, and concerns about drug
diversion and abuse should not constrain prescribing.
Prior to the introduction of OxyContin, many physicians w ere
reluctant to prescribe OPRs
on a long-term basis for common chronic conditions because of
their concerns about addiction,
tolerance, and physiological dependence (80). To overcome

49. what they claimed to be “opiopho-
bia,” physician-spokespersons for opioid manufacturers
published papers and gave lectures in
which they claimed that the medical community had been
confusing addiction with “physical
dependence.” They described addiction as rare and completely
distinct from so-called “physical
dependence,” which was said to be “clinically unimportant” (60,
p. 300). They cited studies with
serious methodological flaws to highlight the claim that the risk
of addiction was less than 1% (28,
45, 52, 59, 62).
In addition to minimizing risks of OPRs, the campaign advanced
by opioid manufacturers
and pain organizations exaggerated the benefits of long-term
OPR use. In fact, high-quality,
562 Kolodny et al.
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PU36CH31-Kolodny ARI 11 February 2015 9:9
long-term clinical trials demonstrating the safety and efficacy
of OPRs for chronic non-cancer
pain have never been conducted. Surveys of patients with
chronic non-cancer pain receiving
long-term OPRs suggest that most patients continued to
experience significant chronic pain and
dysfunction (25, 76). The CDC and some professional societies
now warn clinicians to avoid
prescribing OPRs for common chronic conditions (29).
Although increased opioid consumption over the past two
decades has been driven largely
by greater ambulatory use for chronic non-cancer pain (8),
opioid use for acute pain among
hospitalized patients has also increased sharply. A recent study
found that physicians prescribed
opioids in more than 50% of 1.14 million nonsurgical hospital
admissions from 2009 to 2010,
often in high doses (34). The Joint Commission’s adoption of
the Pain is the Fifth Vital Sign
campaign and federally mandated patient satisfaction surveys
asking patients to rate how often
hospital staff did “everything they could to help you with your
pain” are noteworthy, given the

54. association with increased hospital use of OPRs.
REFRAMING THE OPIOID CRISIS AS AN EPIDEMIC OF
ADDICTION
Policy makers and the media often characterize the opioid crisis
as a problem of nonmedical OPR
abuse by adolescents and young adults. However, several lines
of evidence suggest that addiction
occurring in both medical and nonmedical users, rather than
abuse per se, is a key driver of
opioid-related morbidity and mortality in medical and
nonmedical OPR users.
Opioid Harms Are Not Limited to Nonmedical Users
Over the past decade, federal and state policy makers have
attempted to reduce OPR abuse and
OPR-related overdose deaths. Despite these efforts, morbidity
and mortality associated with OPRs
have continued to worsen in almost every US state (10). Thus
far, these efforts have focused
primarily on preserving access to OPRs for chronic pain
patients while reducing nonmedical
OPR use (89), defined as the use of a medication without a
prescription, in a way other than as
prescribed, or for the experience or feeling it causes. However,
policy makers who focus solely on
reducing nonmedical use are failing to appreciate the high
opioid-related morbidity and mortality
in pain patients receiving OPR prescriptions for medical
purposes.
The incidence of nonmedical OPR use increased sharply in the
late 1990s, peaking in 2002
with 2.7 million new nonmedical users. Since 2002, the

55. incidence of nonmedical use has gradually
declined to ∼1.8 million in 2012 (64, 70) (Figure 3). Although
the number of new nonmedical
users has declined, overdose deaths, addiction treatment
admissions, and other adverse public
health outcomes associated with OPR use have increased
dramatically since 2002.
A comparison of age groups of nonmedical OPR users to age
groups suffering the highest rates
of opioid-related morbidity and mortality suggests that
strategies focused exclusively on reducing
nonmedical OPR use are insufficient (Figure 4). Although past-
month nonmedical use of OPRs
is most common in teenagers and young adults between the ages
of 15 and 24 (65), OPR overdose
deaths occur most often in adults ages 45–54, and the age group
that has experienced the greatest
increase in overdose mortality over the past decade is 55–64
(15), an age group in which medical
use of OPRs is common. Opioid overdoses appear to occur more
frequently in medical OPR users
than in young nonmedical users. For example, in a study of 254
unintentional opioid overdose
decedents in Utah, 92% of the decedents had been receivi ng
legitimate OPR prescriptions from
health care providers for chronic pain (39).
Middle-aged women and the elderly are more likely than other
groups to visit doctors with
complaints of pain (4). The development of iatrogenic opioid
addiction in these groups may
explain why they have experienced the largest increase in
hospital stays resulting from opioid user
www.annualreviews.org • The Opioid Addiction Epidemic 563

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PU36CH31-Kolodny ARI 11 February 2015 9:9
3,000
2,500
2,000
1,500

60. 1,000
500
0
1991 1993 1995 1997 1999 2001 2003 2005 2007 2009 2011
N
u
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b
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o
f n
ew
u
se
rs
(i
n
t
h
o
u
sa
n

61. d
s)
Year
Figure 3
First-time nonmedical use of pain relievers. Source: 64, 70.
disorders since 1993 (56) (Figure 5). Over the past decade,
white women ages 55–64 have also
experienced the largest increase in accidental opioid overdose
deaths (12, 15).
Opioid Addiction Is a Key Driver of Morbidity and Mortality
Accidental opioid overdose is a common cause of death in
individuals suffering from opioid ad-
diction (36). Although overdoses do occur in medical and
nonmedical OPR users who are not
1,400
1,200
1,000
800
600
400
200
0

62. 1,600
15–24 25–34 35–44 45–54 55–64 65+ 15–24 25–34 35–44 45–
54 55–64 65+
N
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in
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r
at

63. e
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,0
00
p
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n
12
10
8
6
4
2
0

64. Age group (2011) Age group (2011)
a Past month nonmedical OPR use by age b OPR-related
unintentional overdose deaths by age
Figure 4
(a) Past month nonmedical OPR use by age versus (b) OPR-
related unintentional overdose deaths by age. Abbreviation:
OPR, opioid
pain reliever. Sources: 58, 68.
564 Kolodny et al.
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65. .3
6:
55
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66. s.
or
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68. .
PU36CH31-Kolodny ARI 11 February 2015 9:9
400
350
300
250
200
100
50
0
150
R
at
e
o
f s
ta
ys
p

69. er
1
00
,0
00
p
o
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la
ti
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n
188.6
70.7 66.6
46.0 51.1
221.8
312.3
338.1
230.8
265.3
18–24
25–44

70. 45–64
65–84
85+
1993 2012
Year
Figure 5
Rate of hospital inpatient stays related to OPR use by adult age
group, 1993 and 2012. Source: 56.
opioid-addicted, consistent findings in samples of OPR
overdose decedents show that deaths are
most common in individuals likely to be suffering from opioid
addiction. A study of 295 unin-
tentional OPR overdose deaths in West Virginia found that four
out of five decedents (80%) had
a history of a substance use disorder (33). Another study found
that among 254 opioid overdose
decedents in Utah, about three-fourths (76%) had relatives or
friends who were concerned about
the decedent’s misuse of opioids prescribed for pain (39).
The sharp increase in the prevalence of opioid addiction is a key
driver of opioid-related
morbidity and mortality. The misattribution of the opioid crisis
to nonmedical use or abuse rather
than to addiction has stymied efforts to address this crisis
because it has led to a focus on policies
to prevent such nonmedical use at the expense of greater
resources committed to preventing and
treating opioid addiction in both medical and nonmedical users.
PREVENTION STRATEGIES
This section organizes strategies for curbing the epidemic of

71. opioid addiction into primary, sec-
ondary, and tertiary prevention. Although some specific
interventions are discussed, we do not
provide an exhaustive list. Rather, our purpose is to demonstrate
that prevention strategies em-
ployed in epidemiologic responses to communicable and
noncommunicable disease epidemics
apply equally well when the disease in question is opioid
addiction. Interventions should focus on
preventing new cases of opioid addiction (primary prevention),
identifying early cases of opioid
addiction (secondary prevention), and ensuring access to
effective addiction treatment (tertiary
prevention).
Primary Prevention
The aim of primary prevention is to reduce the incidence of a
disease or condition. Opioid addiction
is typically chronic, life-long, difficult to treat, and associated
with high rates of morbidity and
mortality. Thus, bringing the opioid addiction epidemic under
control requires effort to prevent
new cases from developing.
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Preventing addiction caused by medical exposure to OPRs. The
incidence of iatrogenic
opioid addiction in patients treated with long-term OPRs is
unknown because adequately designed
prospective studies have not been conducted. However, opioid
use disorders appear to be highly
prevalent in chronic pain patients treated with OPRs. A survey
performed by Boscarino et al.
of 705 chronic pain patients treated in specialty and primary
care outpatient centers found that
26% met the Diagnostic and Statistical Manual of Mental
Disorders (DSM) IV criteria for opioid
dependence, and 35% met DSM V criteria for an opioid use
disorder (6, 7). A systematic review
of studies utilizing opioids for low back pain found that
aberrant drug abuse–related behaviors
suggestive of addiction occurred in up to 24% of patients on

76. long-term OPRs (50). Many patients
on long-term OPRs worry about dependence and addiction and
express a desire to taper or cease
opioid therapy (76).
To reduce the incidence of iatrogenic opioid addiction, health
care professionals must prescribe
opioids more cautiously for both acute and chronic pain.
Unfortunately, the campaign to encourage
OPR prescribing has left many health care providers with a poor
appreciation of opioid risks,
especially the risk of addiction, and an overestimation of opioid
benefits. Despite these risks and
the lack of evidence supporting long-term efficacy, OPR
prescribing for chronic non-cancer pain
increased over the past decade while use of nonopioid
analgesics decreased (20). This pattern
highlights the need for prescriber education that explicitly
corrects misperceptions about OPR
safety and efficacy. If clinicians treating pain more often
substituted nonopioid analgesics and
nonpharmaceutical approaches for OPRs, evidence suggests the
incidence of opioid addiction
would decline and outcomes for patients with chronic non-
cancer pain would improve.
Many prescribers are unaware that evidence of long-term
effectiveness for OPRs is lacking
and that risks, in addition to addiction, include respiratory
depression leading to unintentional
overdose death; serious fractures from falls (71, 77);
hypogonadism and other endocrine effects that
can cause a spectrum of adverse effects (88); increased pain
sensitivity (2); chronic constipation
and serious fecal impaction (81); and chronic dry mouth, which
can lead to tooth decay (79).

77. Providing prescribers with accurate information about opioid
risks and benefits could result in
more informed risk/benefit appraisals. Indeed, one of the
lessons learned from the nineteenth-
century opioid addiction epidemic was that physicians were
educable. By the early 1900s, aggressive
opioid prescribing had become the hallmark of older, less-
competent physicians (5).
Several states, including Iowa, Kentucky, Massachusetts, Ohio,
Tennessee, and Utah, have
passed mandatory prescriber education legislation (89). In
addition, the US Food and Drug Admin-
istration (FDA) is requiring manufacturers of extended release
and long-acting OPRs to sponsor
educational programs for prescribers. Unfortunately, some of
these educational programs, includ-
ing those required by the FDA, imply that OPRs are safe and
effective for chronic non-cancer
pain instead of offering prescribers accurate information about
OPR risks and benefits (84). It
remains unclear whether or not educational programs such as
these will reduce OPR prescribing
for common conditions where risks of use are likely to outweigh
benefits.
Some opioid manufacturers have reformulated OPRs to make
them more difficult to misuse
through an intranasal or injection route. These so-called abuse-
deterrent formulations (ADFs)
may offer safety advantages over easily snorted and injected
OPRs, but they do not render them
less addictive. Opioid addiction, in both medical and
nonmedical OPR users, most frequently
develops through oral use (85). Some opioid-addicted
individuals may transition to intranasal or

78. injection use, but most continue to use OPRs orally (47). Thus,
ADFs should not be considered
a primary prevention strategy for opioid addiction.
In 2013, the New York City Department of Health and Mental
Hygiene released emergency
room guidelines on OPR prescribing (55). Recommendations
included in the guidelines call for
substituting nonopioid analgesics when possible, avoiding use
of extended-release OPRs, and
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82. PU36CH31-Kolodny ARI 11 February 2015 9:9
limiting the supply to three days. Reducing patient exposure to
OPRs and reducing the supply of
excess OPRs in the homes of discharged patients may be
effective strategies for preventing opioid
addiction that can occur from both medical and nonmedical
OPR use.
Preventing addiction caused by nonmedical exposure to OPRs.
Individuals who use OPRs
nonmedically are at risk for developing opioid addiction. Thus,
efforts to reduce nonmedical use
are an important primary prevention strategy. Adolescents and
young adults who experiment with
nonmedical use are most likely to obtain OPRs for free from
friends or family members who had
received a legitimate prescription (70). This information
suggests that more cautious prescribing
is required to prevent nonmedical use of excess OPRs. Unused
OPRs in medicine chests should
be immediately discarded or returned to a pharmacy, which
became permissible in October 2014
after the Drug Enforcement Administration made a federal
regulatory change (82).
Although OPRs have an abuse liability similar to that of heroin
(17), they are commonly per-
ceived as less risky. Seventy-three percent of eighth graders
surveyed in 2013 perceived occasional
use of heroin without a needle as high risk, but only 26%
perceived occasional use of Vicodin as
high risk (41). Eighth graders also perceived occasional Vicodin

83. use as less risky than occasional
marijuana use, less risky than smoking 1–5 cigarettes per day,
and less risky than moderate alcohol
use.
Individuals who perceive the risk of nonmedical OPR use to be
low may be more likely to
misuse OPRs. A 2004 survey found that college students w ho
perceive a low level of risk from
OPRs were 9.6 times more likely to use OPRs nonmedically, as
compared with those who perceive
these medications as harmful (3). Although the ability for
causal inference from this type of cross-
sectional survey is limited, this finding suggests that social
marketing campaigns designed to
increase perceived harmfulness of OPRs may be an effective
prevention strategy.
Secondary Prevention
The aim of secondary prevention is to screen for a health
condition after its onset but before it
causes serious complications. Efforts to identify and treat
opioid-addicted individuals early in the
course of the disease are likely to reduce the risk of overdose,
psychosocial deterioration, transition
to injection opioid use, and medical complications.
Physicians are frequently the source of OPRs for opioid-
addicted medical and nonmedical
users (43). Contacts with medical professionals present valuable
opportunities for early identi-
fication of opioid addiction. However, detection of opioid
addiction in OPR users can be very
difficult. Opioid-addicted chronic pain patients may
demonstrate aberrant drug-related behaviors,

84. such as presenting for early refills. However, some opioid-
addicted pain patients, especially those
prescribed high doses, may not demonstrate drug-seeking
behavior. Opioid-addicted individuals
receiving OPR prescriptions are often reluctant to disclose their
concerns about addiction with
prescribers because they fear being judged, being cut off from a
legitimate supply, or being labeled
as malingerers for feigning pain.
The difficulty of diagnosing opioid addiction in individuals
motivated to conceal their condi-
tion suggests that prescribers should seek collateral information
before prescribing OPRs. Urine
toxicology can be used to verify a patient’s self-reported drug
ingestion history (53). However,
urine toxicology of patients on long-term OPRs is not a reliable
strategy for identifying opioid
addiction. Urine toxicology cannot determine if a patient is
taking extra doses or if a patient is
using OPRs by an intranasal or injection route.
Opioid-addicted individuals may receive OPR prescriptions
from multiple providers, a prac-
tice referred to as “doctor shopping.” Doctor shoppers can be
identified through use of state
www.annualreviews.org • The Opioid Addiction Epidemic 567
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PU36CH31-Kolodny ARI 11 February 2015 9:9
prescription drug monitoring programs (PDMPs). Some state
PDMPs send unsolicited reports
to the medical providers of doctor shoppers. Research suggests
that unsolicited reports increase
prescribers’ ability to detect opioid addiction, sometimes
prompting actions such as coordinating
care with other providers and modifying their own prescribing
practices, as well as screening and
referring for addiction treatment (78).
Prescribers in most states can consult their state PDMP before
prescribing OPRs. PDMPs may
be especially useful in emergency rooms and other settings
where opioid-addicted individuals feign
pain to obtain OPRs. Too often, however, patients identified as

89. doctor shoppers are simply turned
away, without hospital staff attempting to link these patients to
addiction treatment services. Efforts
must be made to help these clinicians understand that drug-
seeking patients are suffering from
the chronic, life-threatening disease of opioid addiction.
One challenge to PDMP effectiveness has been the low rate of
provider use of these data
(48). To increase prescriber utilization, Kentucky, Tennessee,
and New York passed legislation
mandating that prescribers check the PDMP before prescribing
controlled substances. Data from
these states indicate that PDMP utilization increased rapidly
subsequent to the mandate, which
correlated with declines in opioid prescribing (KY, TN, NY)
and a sharp drop in visits to multiple
providers (TN, NY) (35).
Tertiary Prevention
Tertiary prevention strategies involve both therapeutic and
rehabilitative measures once a disease
is firmly established. The goal of tertiary prevention of opioid
addiction is to prevent overdose
deaths, medical complications, psychosocial deterioration,
transition to injection drug use, and
injection-related infectious diseases. Doing so is accomplished
mainly by ensuring that opioid-
addicted individuals can access effective and affordable opioid
addiction treatment.
Opioid addiction treatment. The need for opioid addiction
treatment is great and largely unmet.
According to the NSDUH, an estimated 2.1 million Americans
are addicted to OPRs, and 467,000

90. are addicted to heroin (70). Unfortunately, these estimates
exclude many opioid-addicted pain
patients because NSDUH participants are told by surveyors that
“we are only interested in your
use of prescription pain relievers that were not prescribed for
you or that you used only for the
experience or feeling they caused” (67, p. 124).
In 2005, there were an estimated 10 million chronic pain
patients receiving daily, long-term
treatment with OPRs (8). The continuing increase in opioid
consumption from 2005 to 2011 (42)
suggests that the number may now exceed 10 million. Applying
the prevalence estimates of DSM
IV opioid dependence found by Boscarino et al. (6) in pain
patients taking long-term opioids
would indicate that an additional 2.5 million chronic pain
patients may be opioid-addicted. Thus,
the total number of Americans suffering from opioid addiction
may exceed 5 million.
Treatment of opioid addiction includes pharmacotherapies and
psychosocial approaches, in-
cluding residential treatment, mutual-help programs (e.g.,
Narcotics Anonymous), and 12-Step
treatment programs. These modalities may be used as stand-
alone interventions or in combination
with pharmacotherapy. Psychosocial opioid addiction treatment
approaches show value and are
an important treatment option (63). However, research with
greater specificity and consistency is
needed to better evaluate outcomes.
Pharmacotherapies for opioid addiction include agonist
maintenance with methadone and
partial-agonist maintenance with buprenorphine and antagonist

91. treatment with naltrexone, which
is available in a monthly injection. Methadone and
buprenorphine work by controlling cravings.
Naltrexone works by preventing opioid-addicted individuals
from feeling the effects of opioids.
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95. Naltrexone may be helpful in highly motivated and carefully
selected patients. However, patients
treated with naltrexone may be at increased risk of overdose
death should relapse occur (23).
Multiple well-designed randomized controlled trials provide
strong evidence that buprenor-
phine maintenance and methadone maintenance are safe and
effective treatments for opioid ad-
diction (30, 40, 46, 49, 74, 75). Both buprenorphine and
methadone treatment are associated
with reduced overdose risk and improved maternal and fetal
outcomes in pregnancy (19, 44, 51,
72). Despite strong evidence supporting the use of
buprenorphine and methadone, fewer than
1 million Americans are receiving these treatments (87).
Methadone poses a substantially greater risk of respiratory
depression than does buprenorphine
and can be obtained only from licensed opioid treatment
programs (OTPs). The lack of OTPs
in many communities presents a major challenge to expanding
access to methadone. In contrast,
buprenorphine, a partial opioid agonist, has a better safety
profile than does methadone and can be
prescribed in an office-based setting (26). Barriers to accessing
buprenorphine include federal lim-
its on the number of patients a physician may treat, ineligibility
of nurse practitioners to prescribe
it, and inadequate integration of buprenorphine into primary
care treatment. Access to buprenor-
phine treatment could be expanded if the federal government
eased or remove regulatory barriers.
Harm-reduction approaches. Tertiary prevention strategies also
include harm-reduction ap-

96. proaches to improving health outcomes and reducing overdose
deaths. In the subset of opioid-
addicted individuals who are heroin injection drug users,
evidence suggests that access to syringe
exchange programs can prevent HIV infection (22). These
efforts have been less effective at pre-
venting hepatitis C infection, which is increasing rapidly in
young, white IDUs (32).
Expanding access to naloxone, an opioid overdose antidote, can
prevent overdose deaths by
reversing life-threatening respiratory depression. In the 1990s,
syringe exchange programs began
distributing naloxone to injection drug users for the purpose of
rescuing peers. Evidence shows that
clients of syringe exchange programs demonstrated the ability
to successfully reverse overdoses
when they had been provided with naloxone and training (73).
In addition, providing family
members of opioid-addicted individuals and nonparamedic first
responders with naloxone may be
an effective strategy for rescuing overdose victims (21, 90). At
present, there are more than 188
community-based naloxone distribution programs in 15 states
and the District of Columbia (11).
CONCLUSION
The increased prevalence of opioid addiction, caused by
overprescribing of OPRs, has led to a
parallel increase in opioid overdose deaths. Efforts to address
this crisis that focus exclusively
on reducing nonmedical OPR use have been ineffective. Middle-
aged and elderly individuals
commonly exposed to OPRs for pain treatment have experienced
the largest increase in rates of

97. opioid-related morbidity and mortality. Recognition that opioid
addiction in both medical and
nonmedical users is a key driver of opioid-related morbidity and
mortality will result in a more
effective response to this public health crisis. Just as public
health authorities would approach
other disease outbreaks, efforts must be made to reduce the
incidence of opioid addiction, identify
cases early, and ensure access to effective treatment.
Preventing opioid addiction requires strategies that foster more
cautious and selective OPR
prescribing. However, if prescribing is reduced without also
ensuring access to addiction treatment,
the opioid overdose death rate may remain at a historically high
level and the use of heroin may
continue to increase. Coordinated efforts from federal agencies,
state agencies, health care insurers,
and health care providers are required to address the needs of
millions of Americans now struggling
with this chronic, life-threatening disease.
www.annualreviews.org • The Opioid Addiction Epidemic 569
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DISCLOSURE STATEMENT
Dr. Alexander is Chair of the FDA’s Peripheral and Central
Nervous System Advisory Committee,
serves as a paid consultant to IMS Health, and serves on an IMS
Health scientific advisory board.
This arrangement has been reviewed and approved by Johns
Hopkins University in accordance
with its conflict of interest policies. Ms. Hwang is a current
ORISE Fellow at the FDA.
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PU36-FrontMatter ARI 25 February 2015 11:17
Annual Review of
Public Health
Volume 36, 2015Contents
Symposium: Strategies to Prevent Gun Violence

135. Commentary: Evidence to Guide Gun Violence Prevention in
America
Daniel W. Webster � � � � � � � � � � � � � � � � � �
� � � � � � � � � � � � � � � � � � � � � � � � � �
� � � � � � � � � � � � � � � � � � � � � � � � � �
� � � � � � � 1
The Epidemiology of Firearm Violence in the Twenty-First
Century
United States
Garen J. Wintemute � � � � � � � � � � � � � � � � �
� � � � � � � � � � � � � � � � � � � � � � � � � �
� � � � � � � � � � � � � � � � � � � � � � � � � �
� � � � � � 5
Effects of Policies Designed to Keep Firearms from High-Risk
Individuals
Daniel W. Webster and Garen J. Wintemute � � � � � � � �
� � � � � � � � � � � � � � � � � � � � � � � � � �
� � � � � � � � � � � � �21
Cure Violence: A Public Health Model to Reduce Gun Violence
Jeffrey A. Butts, Caterina Gouvis Roman, Lindsay Bostwick,
and Jeremy R. Porter � � � � �39
Focused Deterrence and the Prevention of Violent Gun Injuries:
Practice, Theoretical Principles, and Scientific Evidence
Anthony A. Braga and David L. Weisburd � � � � � � � � �
� � � � � � � � � � � � � � � � � � � � � � � � � �
� � � � � � � � � � � � � � �55
Epidemiology and Biostatistics
Has Epidemiology Become Infatuated With Methods? A
Historical
Perspective on the Place of Methods During the Classical

136. (1945–1965) Phase of Epidemiology
Alfredo Morabia � � � � � � � � � � � � � � � � � � �
� � � � � � � � � � � � � � � � � � � � � � � � � �
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� � � � � � � �69
Statistical Foundations for Model-Based Adjustments
Sander Greenland and Neil Pearce � � � � � � � � � � � �
� � � � � � � � � � � � � � � � � � � � � � � � � �
� � � � � � � � � � � � � � � � � � � � �89
The Elusiveness of Population-Wide High Blood Pressure
Control
Paul K. Whelton � � � � � � � � � � � � � � � � � � �
� � � � � � � � � � � � � � � � � � � � � � � � � �
� � � � � � � � � � � � � � � � � � � � � � � � � �
� � � � � � 109
The Epidemiology of Firearm Violence in the Twenty-First
Century
United States
Garen J. Wintemute � � � � � � � � � � � � � � � � �
� � � � � � � � � � � � � � � � � � � � � � � � � �
� � � � � � � � � � � � � � � � � � � � � � � � � �
� � � � � � 5
Focused Deterrence and the Prevention of Violent Gun Injuries:
Practice, Theoretical Principles, and Scientific Evidence
Anthony A. Braga and David L. Weisburd � � � � � � � � �
� � � � � � � � � � � � � � � � � � � � � � � � � �
� � � � � � � � � � � � � � �55
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PU36-FrontMatter ARI 25 February 2015 11:17
Unintentional Home Injuries Across the Life Span:
Problems and
Solution
s
Andrea C. Gielen, Eileen M. McDonald, and Wendy Shields �